Thanatic attitudes of nurses working in the intensive care unit

INTRODUCTION

One of the nurse’s duties is to accompany the dying patient. It results from the definition of nursing according to Henderson [1]. Intensive care departments are among those in which the patient’s death occurs very often [2]. Work in a place where many patients die affects the development of a specific attitude towards the death of the person dealing with it. According to research, nursing students do not feel competent do provide end of life care [3], and nurses working at the ICU often are not well prepared to end of life care [4]. Special courses and workshops can help develop the skills of taking care of dying people [5]. On the other hand, psychologists claim that one of the most important factors influencing the creation of a thanatic attitude are personality determinants. However, people who rarely deal with death may not have such a strong attitude [6]. Nurses working in intensive care units, however, do not belong to such a group.
Makselon proposed a typology of attitudes towards death, distinguishing the following in turn:
• mystery – death is a deep secret with a great sense of uncertainty;
• tragic – death is the greatest misfortune, to which the reaction is despair, bitterness, and lack of acceptance;
• terror – the main reaction to death is enormous fear and uncertainty;
• absurdity – death is accompanied by a lack of sense of meaning in life, there is a belief in the hopelessness of existence;
• destructiveness – death is perceived as a lack of opportunities for further human development, interrupt one’s pursuit of goals;
• centrality – death is an important place in the subject of reflection and other activities undertaken by the individual;
• necessity – death is an acceptable event, which results from the experience of death of mainly loved ones, and is considered imminent;
• value – death is perceived as a very important event that can change an entity’s existence for the better, it can be a union with God; it is an exciting experience never known [6].

AIM OF THE STUDY

The aim of the work is to indicate the most common thanatic attitudes presented by nurses working in the intensive care unit.

MATERIAL AND METHODS

The study was performed by diagnostic survey questionnaire technique. The tool was the author’s own questionnaire supplemented with the Scale of Attitudes to Death, which is part of the Inventory of Attitudes to Death by J. Makselon. It consisted of 33 statements attributed to different attitudes towards death. The respondents answered on an ordinal scale from 1 – I completely disagree to 7 – I completely agree. Averaged response results were presented for both individual statements (Table 1) and attitudes, which were made up of groups of statements (Table 2) according to the instruction of the author of the inventory [6]. The value of each typology was calculated on the basis of the individual statements as the mean of all the items. The reliability of the research tool was calculated, and the Cronbach’s α was 0.86, which indicates high reliability of the questionnaire.
The study took place in the anaesthesiology and intensive care unit of the University Hospital in Krakow in January-March 2015. The survey was addressed to nurses working in the intensive care unit. Consent to perform the study was issued by the Bioethics Committee of the Krakow Academy of Andrzej Frycz Modrzewski (KBKA18/0/2015). The obtained data were coded in the MS Excel spreadsheet and then subjected to statistical analysis in the StatSoft Statistica 12 program. Quantitative variables were analysed by descriptive statistics methods (arithmetic mean, median, standard deviation). To compare quantitative variables with normal distribution, a parametric Pearson correlation coefficient test was used. For the analysis of other variables, the distribution of which differed from normal (p < 0.05 for the Shapiro-Wilk test), a nonparametric Spearman’s rank correlation coefficient test was used. The normality of variable distribution was tested by the Shapiro-Wilk test. The critical value was used to interpret statistical significance, where p < α was considered to be a statistically significant correlation.

RESULTS

The study group consisted of 108 people in total: 99 women (92%) and 9 men (8%). The age of the study participants ranged from 22 to 61 years. The average age was 34 years (SD = 8.53). The median age of the respondents was 32 years. Quartiles II and III were occupied by people aged 26-40 years. The seniority of the nurses surveyed ranged from 2.5 months to 31 years. On average, it was about 10 years (SD = 8.67). The median seniority was 8.5 years. The work internship of nurses in the intensive care unit was 5 years (SD = 5.54) and the median was 2 years. Over half of the respondents were married, 39% were unmarried, and nearly 10% were respondents living in relationships other than married. Nearly half of the respondents lived in a city with a population of over 100,000. Rural residents accounted for less than 40%. Other people lived in smaller cities. Respondents were asked about their religiosity. The vast majority described themselves as “religious” (82.4%). Almost all respondents experienced patient deaths in their work (99.1%). The death of a loved one had also been experienced by the majority of people in the study (60.2%).
The attitudes most represented by the study participants were those of value (4.93; SD = 0.79) and necessity (4.58; SD = 1.00). The low standard deviation of the response for the attitude of value suggests a large similarity of individual responses within a given attitude (Table 3).
The obtained results indicate the lack of centrality in relation to death among nurses working in the intensive care unit (2.81; SD = 0.88). The attitude of absurdity appears to a small extent (3.54; SD = 1.33) (Table 1).
Among the individual statements of the Inventory of Attitudes Towards Death, the most representative approaches of the studied group were as follows: “It seems to me that the right attitude to death can help a person live a better life” (5.8; SD = 1.20), “When I learn about the death of a loved one, I feel anxiety” (5.35; SD = 1.47), and “The death of friends and relatives makes me aware that you cannot escape your own death” (5.22; SD = 1.60). The statements that nurses least often agreed to were as follows: “All my life and work are based on the thought of death” (2.25; SD = 1.32) and “The problem of death occupies a central place in my consciousness” (2.93; SD = 1.38) (Table 2).
Most thanatic attitudes slightly positively (0.21 ≤ r ≤ 0.3) correlated with the age of the respondents, i.e. with the increase in the age of nurses, the intensity of thanatic attitudes such as tragedy, terror, absurdity, destructiveness, centrality, and value increased. The attitude of tragedy correlated most strongly with age.
Analysing attitudes towards the death of nurses regarding their seniority in the intensive care unit, no statistically significant relationships were found (p > 0.05) (Fig. 1). When assessing the impact of the frequency of experiencing death of patients, the examined nurses were divided into 2 groups: 10 and less experienced deaths, and more than 10 experienced deaths. The analysis shows that the frequency of deaths on the call time of individual subjects did not have a significant impact on the diversity of attitudes towards death. In all cases, p > 0.05 (Table 4).

DISCUSSION

The attitudes of nurses towards death have been examined many times over the last years. The research concerned nurses working in various hospital wards and other healthcare facilities. Most often, researchers used proprietary questionnaires in which they examined the emotions and behaviours associated with death. The analysed literature shows that the most common emotional reactions to death in the work of nurses were sadness, regret, and anxiety but also peace [7-11].
On the basis of emotions accompanying death and dying, the study by Dębska et al. [11] identified 3 types of attitudes towards death that were expressed by respondents: the emotional type – people strongly experiencing the death of patients, which affected their professional and private life; the distanced type (as opposed to the emotional type) – a manifestation of indifference to the death of the sick and treating the emotional approach as unprofessional; and a neutral type – people experiencing negative emotions in connection with the death of patients, but controlling their level and impact on other spheres of life. Similar categories of attitudes were adopted in the study of the attitudes towards death of paramedics, also specifying 3 types: emotional, distant, and neutral [12]. In our study, there was no strong predominance of negative thanatic attitudes (tragic, horrific, destructive) in nurses working in the intensive care unit, although a significant proportion of the respondents showed them (tragic – 63%, terror – 65%, destructiveness – 53% of respondents). The main attitudes of the respondents were the attitude of values (85%) and the attitude of necessity (71%). This may be due to the specifics of working in a ward in which a patient’s death occurs very often. The attitude of values is characterized by the interpretation of death as a very important event, giving the possibility of experiencing a better reality and meeting God [13]. According to Kolonko and Sleziona [8, 9], the experience of working with dying people teaches respect for life, humbleness, and sensitivity, and it makes us aware of the fragility of human existence.
The attitude of necessity, which was strongly represented by the respondents in our study (71%), is characterized by a deep understanding of death as the end of life. It is associated with the inevitability of dying and may result from the experience of death of loved ones [13]. Similarly, in the study by Kolonko et al. [8] the surveyed nurses most often experienced peace at the time of the patient’s death, treating death as the natural end of life. In the Sleziona and Krzyżanowski study [9], the attitudes expressed by the nurses were assessed as positive. The following were listed in detail: a partnership attitude (based on patient autonomy and focused on the exchange of values in the patient-nurse relationship), a philosophical and heterocentric attitude (the overarching goal of such an attitude is the feeling of being needed), and a religious attitude (based on faith in the afterlife and defining death as the beginning of a better life). Other findings were revealed in the study among the health science students by Pérez-de la Cruz – respondents displayed high levels of fear and anxiety towards death [14].
In the author’s study, the occurrence of some thanatic attitudes in nurses positively correlates with age (attitudes: tragedy [r = 0.3], horror [r = 0.3], absurdity [r = 0.3], destructiveness [r = 0.3], centrality [r = 0.2], values [r = 0.2]) and does not depend on the length of internship in the intensive care unit. Nurses experiencing the death of patients, with age, more often reflect on their own death, which raises their rather negative association of dying (attitude: tragedy, horror, absurdity, destructiveness). In research by Kraitenberger et al. no associations were found between exposure to death and suffering and attitudes toward death among hemo-oncologists [15].
In the study by Gaworska-Krzemińska [16], attitudes towards death among nurses also correlated with the seniority of the respondents. Zhang et al. found a correlation between nurses’ attitudes towards death and their subjective well-being [17]. Barnett et al. claimed that among hospice nurses more positive attitudes toward care of the dying were associated with lower fear of death and death avoidance [18]. On the other hand, Üstükuş and Eskimez showed in their research that as the death anxiety of nurses increased, their avoidance attitudes towards dying patients decreased [19]. However, a positive correlation between death anxiety and dying patient avoidance behaviour among nurses was shown in the Turkish study by Pehlivan et al. [20].

CONCLUSIONS

Nurses working in the intensive care unit most often show an attitude of necessity and value regarding death.
The nurses to a lesser extent presented an attitude to death that was characterised as “centrality” or “absurdity” than the remaining typological categories.
The attitudes of the nurses related to death depended on age, while the length of work in the intensive care unit and the number of experienced deaths did not affect their diversity.

Disclosure

The authors declare no conflict of interest.

References